Gentile, Gloria NEW YORK STATE DEPARTMENT OF HEALTH ` % # V 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gloria Gentile Female
':1 Date of Death Age If Veteran of U.S. Armed Forces,
August 6,2012 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
elManner of Death Natural Cause Accident ❑Homicide Suicide 1-1 Undetermined n Pending
l Circumstances Investigation
0 Medical Certifier Name Title
P.' Frances Bollinger,MD
Address
Glens Falls,NY
.o. Death Certificate Filed District Number RegisterNumber
:::::1 City, Town or Village Glens Falls,NY I 5601 7` y
El Burial Date Cemetery or Crematory
❑Entombment August 8,2012 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 _ Date Point of
N _Transportation Shipment
p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
`:°;+ Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
e:1 Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I°"' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Sr / -7 I I Registrar of Vital Statistics L.JL,
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W •
Date of Disposition 15-8-lZ Place of Disposition �,.tliwu Cr9Orto..
Ili
(address)
Cl)
CC (section) A 4 (lot number)- (grave number)
pName of Sexton or Person in Charge of Premises Z'hi la /� en. -
`ai
Z (please print)
Signature tili " V"T Title C Re MA-TOrj,
(over)
DOH-1555(02/2004)